THE SAFETY AND QUALITY OF
IN THE UNITED STATES
Committee on Reproductive Health Services:
Assessing the Safety and Quality of Abortion Care in the U.S.
Board on Population Health and Public Health Practice
Board on Health Care Services
Health and Medicine Division
A Consensus Study Report of
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This activity was supported by contracts between the National Academy of Sciences and The David and Lucile Packard Foundation, The Grove Foundation, The JPB Foundation, The Susan Thompson Buffett Foundation, Tara Health Foundation, and William and Flora Hewlett Foundation. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project.
International Standard Book Number-13: 978-0-309-46818-3
International Standard Book Number-10: 0-309-46818-3
Digital Object Identifier: https://doi.org/10.17226/24950
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Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2018. The safety and quality of abortion care in the United States. Washington, DC: The National Academies Press. doi: https://doi.org/10.17226/24950.
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COMMITTEE ON REPRODUCTIVE HEALTH SERVICES: ASSESSING THE SAFETY AND QUALITY OF ABORTION CARE IN THE U.S.
B. NED CALONGE (Co-Chair), University of Colorado
HELENE D. GAYLE (Co-Chair), Chicago Community Trust
WENDY R. BREWSTER, University of North Carolina at Chapel Hill School of Medicine
LEE A. FLEISHER, University of Pennsylvania Perelman School of Medicine
CAROL J. ROWLAND HOGUE, Emory University Rollins School of Public Health
JODY RAE LORI, University of Michigan School of Nursing
JEANNE MIRANDA, University of California, Los Angeles
RUTH MURPHEY PARKER, Emory University School of Medicine
DEBORAH E. POWELL, University of Minnesota Medical School
EVA K. PRESSMAN, University of Rochester Medical Center
ALINA SALGANICOFF, Kaiser Family Foundation
PAUL G. SHEKELLE, The RAND Corporation
SUSAN M. WOLF, University of Minnesota
JILL EDEN, Study Director
KATYE MAGEE, Research Associate
MATTHEW MASIELLO, Research Assistant
ANNA MARTIN, Senior Program Assistant
ROSE MARIE MARTINEZ, Senior Director, Board on Population Health and Public Health Practice
SHARYL NASS, Director, Board on Health Care Services
HOPE HARE, Administrative Assistant
PATRICK BURKE, Senior Financial Officer
MISRAK DABI, Financial Associate (from June 2017)
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This Consensus Study Report was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published report as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process.
We thank the following individuals for their review of this report:
REBECCA H. ALLEN, Brown University
DONALD M. BERWICK, Institute for Healthcare Improvement
CLAIRE BRINDIS, University of California, San Francisco
PONJOLA CONEY, Virginia Commonwealth University
VANESSA K. DALTON, University of Michigan
C. NEILL EPPERSON, University of Pennsylvania Perelman School of Medicine
DANIEL GROSSMAN, University of California, San Francisco
AMY LEVI, University of New Mexico College of Nursing
HEIDI D. NELSON, Oregon Health & Science University
WILLIE J. PARKER, Physicians for Reproductive Health
ROBERT L. PHILLIPS, JR., American Board of Family Medicine
SARA ROSENBAUM, The George Washington University Milken Institute School of Public Health
MICHAEL W. VARNER, University of Utah School of Medicine
GAIL R. WILENSKY, Project HOPE
SUSAN F. WOOD, The George Washington University
Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations of this report, nor did they see the final draft before its release. The review of this report was overseen by ALFRED O. BERG, University of Washington, and ENRIQUETA C. BOND, Burroughs Wellcome Fund. They were responsible for making certain that an independent examination of this report was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the authoring committee and the National Academies.
The committee and staff are indebted to a number of individuals and organizations for their contributions to this report. We extend special thanks to all the individuals who were essential sources of information, generously giving their time and knowledge to further the committee’s efforts. Thank you to Elizabeth Brown, Sidney Callahan, Olivia Cappello, Nancy Chescheir, Mitch Creinin, Carrie Cwiak, Ann Davis, Diana Greene Foster, Marji Gold, Alisa Goldberg, Kristy Goodman, Jane Henney, Susan Higginbotham, Elizabeth Janiak, Tara Jatlaoui, Rachel Jones, Uta Landy, Amy Levi, Steve Lichtenberg, Abigail Long, Ana McKee, Michael Raggio, Matthew Reeves, Debra Stulberg, Diana Taylor, Stephanie Teal, Ushma Upadhyay, Carl Weiner, Kari White, Beverly Winikoff, and Susan Wood.
Thank you as well to the following individuals, who provided testimony to the committee:
BONNIE SCOTT JONES, Senior Policy Advisor, Advancing New Standards in Reproductive Health (ANSIRH), University of California, San Francisco;
SARAH ROBERTS, Associate Professor, ANSIRH, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco; and
JULIET ROGERS, Assistant Professor, Health Management and Policy, University of Michigan.
Funding for this study was provided by The David and Lucile Packard Foundation, The Grove Foundation, The JPB Foundation, The Susan Thompson Buffett Foundation, Tara Health Foundation, and William and Flora Hewlett Foundation. The committee appreciates the opportunity and support extended by the sponsors for the development of this report.
Many within the Health and Medicine Division (HMD) of the National Academies of Sciences, Engineering, and Medicine were helpful to the study staff. The committee would like to thank Rebecca Morgan and the National Academies Research Center staff for their assistance in the committee’s research efforts. We would also like to thank Patrick Burke and Misrak Dabi (HMD Offices of Finance and Administration); Chelsea Frakes, Lauren Shern, and Taryn Young (HMD Executive Office); and Greta Gorman, Nicole Joy, and Bettina Ritter (HMD Office of Communications).
2 THE SAFETY AND QUALITY OF CURRENT ABORTION METHODS
Safety and Effectiveness of Current Abortion Methods
Use of Analgesia, Sedation, and Anesthesia in Abortion Care
State Regulation of Abortion Care
3 ESSENTIAL CLINICAL COMPETENCIES FOR ABORTION PROVIDERS
Required Clinical Competencies
Which Providers Have the Clinical Skills to Perform Abortions?
Training of Physicians and Advanced Practice Clinicians
Availability of Trained Clinicians
Future Childbearing and Pregnancy Outcomes
A Biographical Sketches of Committee Members
Boxes, Figures, and Tables
S-1 Charge to the Committee on Reproductive Health Services: Assessing the Safety and Quality of Abortion Care in the U.S.
S-2 The Six Dimensions of Health Care Quality
1-1 Charge to the Committee on Reproductive Health Services: Assessing the Safety and Quality of Abortion Care in the U.S.
1-3 The Six Dimensions of Health Care Quality
1-4 Types of Research Reviewed for This Study
2-1 FDA Risk Evaluation and Mitigation Strategy (REMS) Program for Mifeprex
S-1 Analytic framework for assessing the quality of abortion care
1-1 Continuum of abortion care
1-2 Abortion rate, United States, 1973–2014
1-3 Percentage and cumulative percentage of outpatient abortions by weeks’ gestation, 2014–2015
1-4 Percentage of abortion-providing facilities accounted for by each facility type and percentage of abortions performed in each type of facility, 2014 (n = 1,671)
1-5 Median distance to the nearest abortion-providing facility by county, 2014
1-6 The committee’s analytic framework for assessing the quality of abortion care
3-1 Selected residencies and fellowships offering abortion training in the United States
3-2 Regulations defining the level of provider credentialing required to provide abortions, by state and abortion method
S-1 Does Abortion Care in the United States Meet the Six Attributes of Quality Health Care?
1-1 Overview of State Abortion-Specific Regulations That May Impact Safety and Quality, as of September 1, 2017
1-2 Characteristics of Women Who Had an Abortion in an Outpatient Setting in 2014, by Percent
2-1 Selected Organizations That Issue Clinical Guidelines on Abortion Care
2-2 Levels and Effects of Analgesia, Sedation, and Anesthesia
2-3 Minimum Facility Requirements Related to Level of Sedation for Medication, Aspiration, and Dilation and Evacuation (D&E) Abortions
2-4 Comparison of Mortality Rates for Abortion, Childbirth, Colonoscopy, Dental Procedures, Plastic Surgery, and Tonsillectomy, United States
3-1 Required Competencies by Type of Abortion Procedure
4-1 Studies Assessing the Association Between Abortion and Subsequent Pregnancy Complications Using Record-Linkage Methods
4-2 Studies Assessing the Association Between Abortion and Preterm Birth (PTB), Low Birthweight (LBW), and Small for Gestational Age (SGA) Using Record-Linkage Methods
5-1 Does Abortion Care in the United States Meet the Six Attributes of Quality Health Care?